Hemodialysis for infants,children, and adolescents

Children with chronic kidney disease stage 5 requiring dialysis can be treated by peritoneal or hemodialysis. In the United Kingdom nearly twice as many children receive peritoneal dialysis compared with hemodialysis. Technical aspects of pediatric hemodialysis are challenging and include the relative size of extracorporeal circuit and child's blood volume, assessment of adequacy,technical and complications of vascular access. Alternatives to standard hospital‐based hemodialysis are also increasingly available. Optimizing nutritional status with the support of specialist pediatric dietitians is key to the management of children receiving hemodialysis. The effects of chronic illness on growth and school achievement, as well as the psychological, emotional, and social development of the child should not be underestimated. This review focuses on the above elements and highlights common pediatric practice in the United Kingdom.     

Cognitive impairment in a patient with COVID-19 on hemodialysis: Too dangerous to neglect!

Neurological manifestations of coronavirus disease 2019 (COVID-19) often have tragic repercussions. Although many reports of neurological complications of severe acute respiratory syndrome coronavirus 2 infection exist, none of them are of patients on hemodialysis, who have a fivefold greater risk of stroke than the general population. In this report, we emphasize the importance of being vigilant for mild stroke in high risk populations—such as patients on hemodialysis—with COVID-19, since these conditions have overlapping symptoms.     

One-year persistence of neutralizing anti-SARS-CoV-2 antibodies in dialysis patients recovered from COVID-19

The immunological mechanisms that modulate immune response to SARS-CoV-2 infection remain elusive. Little is known on the magnitude and the durability of antibody response against COVID-19. There is consensus that patients with immune dysfunction, such as dialysis patients, may be unable to mount a robust and durable humoral immunity after infections. Recent studies showed that dialysis patients seroconverted after COVID-19, but data on the durability of the immune response are missing. We reported the data of a durable anti-spike protein seroconversion after natural SARS-CoV-2 infection in three patients on hemodialysis with a mean age of 67.2 ± 13.8 years. A mean antibody titer of 212.6 ± 174.9 UA/ml (Liaison®, DiaSorin) was found after one year (range, 366–374 days) from the diagnosis of COVID-19. In conclusion, this case series provided evidence that patients receiving hemodialysis who recovered from severe COVID-19 were able to mount a long-lasting immune response against SARS-CoV-2. Although the protective capacity of this long-term immunity remains to be determined, these patients did not report signs of reinfection after recovery from COVID-19.     

Psychosocial aspects of children and families treated with hemodialysis

Introduction: The aim of this study was to analyze the selected psychosocial aspects of chronic kidney disease in children treated with hemodialysis (HD). Methods: The study included 25 children treated with HD aged 2 to 18 years and their parents. Data concerning the illness and socio‐demographic parameters was collected. We used the Paediatric Quality of Life Inventory (PedsQL) for patients and for their parents the PedsQL‐proxy version, General Health Questionnaire (GHQ‐12), Berlin Social Support Scales (BSSS), and the Caregivers Burden Scale (CBS) to evaluate health‐related quality of life (QoL) of HD children and their primary caregivers. Findings: In the PedsQL test, the QoL of HD children was lower than in healthy children. Children treated with HD assessed their QoL on the PedsQL questionnaire higher than the primary caregivers, on all subscales as well as an overall health‐related QoL. Scoring below 2 on the GHQ‐12 test was reported in 56% of mothers, which may indicate that psychological symptoms have intensified. There was no correlation between BSSS, CBS, and GHQ‐12. Discussion: The assessment of QoL in pediatric patients would allow for the earliest possible identification of their nonsomatic problems and irregularities. This could, consequently, contribute to improving QoL in both children with chronic kidney disease and their families.     

Poor correlation between coronary artery calcification and obstructive coronary artery disease in an end-stage renal disease patient

Vascular calcification is highly prevalent and often severe in patients with chronic kidney disease. Arterial calcification in patients with chronic kidney disease can result from the deposition of mineral along the intimal layer of arteries in conjunction with atheromatous plaques or from calcium deposition in the medial wall of arteries, also known as Monckeberg's sclerosis. Whether coronary artery calcium scores as measured by electron beam computed tomography correlate with occlusive atherosclerotic disease in the dialysis population is uncertain. Here we report a case of an asymptomatic patient with diabetes mellitus and end-stage renal disease undergoing maintenance hemodialysis, who was found to have extremely elevated coronary artery calcium scores on electron beam computed tomography, but varied degrees of atherosclerotic plaque in her coronary arteries on coronary angiography. This suggests that in addition to the calcification anticipated in a remodeled intima, a proportion of the calcification is also likely to be in the arterial media. Thus, this case demonstrates that even an extremely high coronary calcium score may not be a satisfactory surrogate marker for obstructive atherosclerosis in elderly diabetic dialysis patients.     

Spontaneous retroperitoneal hemorrhage due to acquired cystic kidney disease

A patient with end-stage renal disease on maintenance hemodialysis developed sudden severe abdominal pain and distension. He suffered a decline in his hematocrit and subsequent abdominal imaging revealed a large left-sided retroperitoneal hemorrhage in the setting of atrophic, severely cystic kidneys. He underwent selective left renal artery angiography and embolization due to continued hemorrhage with stabilization in his condition. However, he became paraparetic within hours of the embolization procedure due to spinal cord infarct. Acquired cystic kidney disease is a very common entity in patients with chronic kidney disease. Complications include cystic hemorrhage or infection, erythrocytosis, and renal cell carcinoma. Screening of patients for cystic disease and malignant transformation remains a controversial topic; however, most advocate abdominal imaging after 3 to 5 years on dialysis.     

Two additional cases of metformin‐associated encephalopathy in patients with end‐stage renal disease undergoing hemodialysis

We report on two additional cases of metformin‐associated encephalopathy in patients with end‐stage renal disease (ESRD) undergoing hemodialysis. Two patients were seen at our hospital with abnormal neurological signs and symptoms. Magnetic resonance imaging (MRI) revealed the same pattern of high signal intensity in both basal ganglia in T2‐weighted images in the two patients. The two patients had started taking metformin 5 and 6 weeks earlier at the same dose of 1000 mg per day. Metformin was immediately stopped, and regular hemodialysis was conducted. Their signs and symptoms resolved completely after these measures. The high signal intensity in both ganglia in T2‐weighted MRI also disappeared. We should suspect metformin‐induced encephalopathy and withdraw the drug when presented with diabetic patients with chronic kidney disease and neurological signs and symptoms of unknown cause.     

一种针对新型冠状病毒肺炎的准确、快速、便携式双功能电检测仪

新型冠状病毒肺炎(COVID-19)正在多个国家快速传播,已经导致了严重的全球大流行.由于目前没有针对此类病人的特效药和针对此病毒的疫苗,准确、快速地进行新冠病人检测成为了控制大流行最有效的措施.本文中我们开发了一种基于石墨烯场效应晶体管的便携式双功能电检测仪,其通过核酸互补杂交或者抗原-抗体特异性结合作用,能分别进行...     

Hyponatremia in patients with chronic kidney disease

Hyponatremia is a common condition encountered in clinical practice. A number of studies have associated low serum sodium levels with increased mortality in various patient populations, such as hospitalized patients and patients with various comorbid conditions; recent studies have shown that individuals with chronic kidney disease also are afflicted by hyponatremia. However, few studies have focused on patients with hemodialysis. Evidence supporting the incidence and prevalence of hyponatremia, clinical characteristics and the association with patient outcomes with hemodialysis is limited. In the present review, we examined the physiology and pathophysiology of water and sodium balance with a special emphasis on changes occurring during end‐stage renal disease. The outcomes in patients undergoing hemodialysis were associated with low serum sodium. We evaluated the associations between hyponatremia and mineral bone abnormalities and discussed the elevated incidence and prevalence of difficult clinical outcomes associated with hyponatremia. We also provided specific recommendations for hemodialysis treatment in hyponatremic patients.     

Polycythemia due to obstructive sleep apnea in a patient on hemodialysis

Both anemia and sleep disordered breathing are common in patients with dialysis‐dependent stage 5 chronic kidney disease. Erythrocytosis resulting from obstructive sleep apnea (OSA) is rare in the general population and has never been described in the hemodialysis population. We present a case of asymptomatic isolated erythrocytosis and elevated serum erythropoietin level in an otherwise well and previously erythropoietin‐dependent chronic hemodialysis patient with chronic kidney disease secondary to ischemic nephropathy. There was no history or symptoms of cardio‐pulmonary or hepatic diseases nor any relevant family history. Screening work‐up for malignancies was negative. The clinical history was highly suggestive of OSA and severe OSA (respiratory disturbance index of 59) was confirmed by polysomnographic studies. Successful treatment of the OSA with continuous positive airway pressure resulted in permanent stabilization of the hemoglobin to levels below 13 g/dL without the need for repeated phlebotomies and in dramatic lowering of serum erythropoietin levels. To our knowledge, this is the first case of OSA mediated erythrocytosis in a dialysis patient documented in the literature.     

Infection,inflammation and intervention: mechanistic modelling of epithelial cells in COVID-19

While the pathological mechanisms in COVID-19 illness are still poorly understood, it is increasingly clear that high levels of pro-inflammatory mediators play a major role in clinical deterioration in patients with severe disease. Current evidence points to a hyperinflammatory state as the driver of respiratory compromise in severe COVID-19 disease, with a clinical trajectory resembling acute respiratory distress syndrome, but how this ‘runaway train’ inflammatory response emerges and is maintained is not known. Here, we present the first mathematical model of lung hyperinflammation due to SARS-CoV-2 infection. This model is based on a network of purported mechanistic and physiological pathways linking together five distinct biochemical species involved in the inflammatory response. Simulations of our model give rise to distinct qualitative classes of COVID-19 patients: (i) individuals who naturally clear the virus, (ii) asymptomatic carriers and (iii–v) individuals who develop a case of mild, moderate, or severe illness. These findings, supported by a comprehensive sensitivity analysis, point to potential therapeutic interventions to prevent the emergence of hyperinflammation. Specifically, we suggest that early intervention with a locally acting anti-inflammatory agent (such as inhaled corticosteroids) may effectively blockade the pathological hyperinflammatory reaction as it emerges.     

Acquired perforating dermatoses in patients with diabetic kidney disease on hemodialysis

Acquired perforating dermatoses (APD) is an uncommon skin disorder seen in patients with diabetes mellitus, chronic kidney disease, or both together. We present the clinicopathological features of APD in patients with diabetic kidney disease and discuss the recent advances in management. We retrospectively analyzed the data of 8 patients with APD presenting to our center. All patients were known cases of Type 2 diabetes and chronic kidney disease requiring maintenance dialysis. Acquired perforating dermatoses was diagnosed based on clinical presentation of itchy, keratotic papulonodular lesions, and characteristic histopathological features of transepithelial elimination on skin biopsy. The patients were subdivided into 4 types of APD based on the biopsy features. All our patients had Type 2 diabetes over 5 years duration and were on maintenance dialysis for more than 6 months before presentation. Acquired perforating dermatoses symptoms appeared 2 to 6 months before presentation. The majority of patients (6/8) had a subtype of reactive perforating collagenosis. All the patients showed significant resolution with topical glucocorticoid therapy. Acquired perforating dermatoses is a skin complication seen in Type 2 diabetes, chronic kidney disease, or when both are present together. Early identification and therapy prevents the associated morbidity.     

Clinical Characteristics and Outcomes of Type 2 Diabetes Patients Infected with COVID-19: A Retrospective Study

Diabetes and its related metabolic disorders have been reported as the leading comorbidities in patients with coronavirus disease 2019 (COVID-19). This clinical study aims to investigate the clinical features, radiographic and laboratory tests, complications, treatments, and clinical outcomes in COVID-19 patients with or without diabetes. This retrospective study included 208 hospitalized patients (≥ 45 years old) with laboratory-confirmed COVID-19 during the period between 12 January and 25 March 2020. Information from the medical record, including clinical features, radiographic and laboratory tests, complications, treatments, and clinical outcomes, were extracted for the analysis. 96 (46.2%) patients had comorbidity with type 2 diabetes. In COVID-19 patients with type 2 diabetes, the coexistence of hypertension (58.3% vs 31.2%), coronary heart disease (17.1% vs 8.0%), and chronic kidney diseases (6.2% vs 0%) was significantly higher than in COVID-19 patients without type 2 diabetes. The frequency and degree of abnormalities in computed tomography (CT) chest scans in COVID-19 patients with type 2 diabetes were markedly increased, including ground-glass opacity (85.6% vs 64.9%, P < 0.001) and bilateral patchy shadowing (76.7% vs 37.8%, P < 0.001). In addition, the levels of blood glucose (7.23 mmol·L⁻¹ (interquartile range (IQR): 5.80–9.29) vs 5.46 mmol·L⁻¹ (IQR: 5.00–6.46)), blood low-density lipoprotein cholesterol (LDL-C) (2.21 mmol·L⁻¹ (IQR: 1.67–2.76) vs 1.75 mmol·L⁻¹ (IQR: 1.27–2.01)), and systolic pressure (130 mmHg (IQR: 120–142) vs 122 mmHg (IQR: 110–137)) (1 mmHg = 133.3 Pa) in COVID-19 patients with diabetes were significantly higher than in patients without diabetes (P < 0.001). The coexistence of type 2 diabetes and other metabolic disorders is common in patients with COVID-19, which may potentiate the morbidity and aggravate COVID-19 progression. Optimal management of the metabolic hemostasis of glucose and lipids is the key to ensuring better clinical outcomes. Increased clinical vigilance is warranted for COVID-19 patients with diabetes and other metabolic diseases that are fundamental and chronic conditions.     

Is home hemodialysis a practical option for older people?

An increasing demand for in-center dialysis services has been largely driven by a rapid growth of the older population progressing to end-stage kidney disease. Since the onset of the COVID-19 pandemic, efforts to encourage home-based dialysis options have increased due to risks of infective transmission for patients receiving hemodialysis in center-based units. There are various practical and clinical advantages for patients receiving hemodialysis at home. However, the lack of caregiver support, cognitive and physical impairment, challenges of vascular access, and preparation and training for home hemodialysis (HHD) initiation may present as barriers to successful implementation of HHD in the older dialysis population. Assessment of an older patient's frailty status may help clinicians guide patients when making decisions about HHD. The development of an assisted HHD care delivery model and advancement of telehealth and technology in provision of HHD care may increase accessibility of HHD services for older patients. This review examines these factors and explores current unmet needs and barriers to increasing access, inclusion, and opportunities of HHD for the older dialysis population.     

Digital clubbing as an unusual complication associated with severe secondary hyperparathyroidism: report of two cases

Digital clubbing due to secondary hyperparathyroidism has been described as an unusual complication among patients with chronic kidney disease undergoing maintenance hemodialysis therapy. Although the pathogenesis of digital clubbing is unknown, certain growth factors such as platelet-derived growth factor and hepatocyte growth factor have been associated with this clinical syndrome. Two patients of our renal unit population presented this unique clinical feature bilaterally, among the other clinical findings of severe secondary hyperparathyroidism. Both patients were subjected to parathyroidectomy. Histological examination revealed diffuse hyperplasia of parathyroid glands. Despite the improvement of clinical symptoms and laboratory findings of secondary hyperparathyroism after parathyroidectomy, digital clubbing remained unchanged.     

Towards an Artificial Intelligence Framework for Data-Driven Prediction of Coronavirus Clinical Severity

The virus SARS-CoV2, which causes coronavirus disease (COVID-19) has become a pandemic and has spread to every inhabited continent. Given the increasing caseload, there is an urgent need to augment clinical skills in order to identify from among the many mild cases the few that will progress to critical illness. We present a first step towards building an artificial intelligence (AI) framework, with predictive analytics (PA) capabilities applied to real patient data, to provide rapid clinical decision-making support. COVID-19 has presented a pressing need as a) clinicians are still developing clinical acumen to this novel disease and b) resource limitations in a surging pandemic require difficult resource allocation decisions. The objectives of this research are: (1) to algorithmically identify the combinations of clinical characteristics of COVID-19 that predict outcomes, and (2) to develop a tool with AI capabilities that will predict patients at risk for more severe illness on initial presentation. The predictive models learn from historical data to help predict who will develop acute respiratory distress syndrome (ARDS), a severe outcome in COVID-19. Our results, based on data from two hospitals in Wenzhou, Zhejiang, China, identified features on initial presentation with COVID-19 that were most predictive of later development of ARDS. A mildly elevated alanine aminotransferase (ALT) (a liver enzyme), the presence of myalgias (body aches), and an elevated hemoglobin (red blood cells), in this order, are the clinical features, on presentation, that are the most predictive. The predictive models that learned from historical data of patients from these two hospitals achieved 70% to 80% accuracy in predicting severe cases.     

Nanoparticle approaches against SARS-CoV-2 infection

Coronavirus disease 2019 (COVID-19), caused by the highly contagious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become the worst pandemic disease of the current millennium. To address this crisis, therapeutic nanoparticles, including inorganic nanoparticles, lipid nanoparticles, polymeric nanoparticles, virus-like nanoparticles, and cell membrane-coated nanoparticles, have all offered compelling antiviral strategies. This article reviews these strategies in three categories: (1) nanoparticle-enabled detection of SARS-CoV-2, (2) nanoparticle-based treatment for COVID-19, and (3) nanoparticle vaccines against SARS-CoV-2. We discuss how nanoparticles are tailor-made to biointerface with the host and the virus in each category. For each nanoparticle design, we highlight its structure–function relationship that enables effective antiviral activity. Overall, nanoparticles bring numerous new opportunities to improve our response to the current COVID-19 pandemic and enhance our preparedness for future viral outbreaks.     

The Efficacy and Safety of Triazavirin for COVID-19: A Trial Protocol

The coronavirus disease 2019 (COVID-19), a pneumonia caused by a novel coronavirus, was reported in December 2019. COVID-19 is highly contagious and has rapidly developed from a regional epidemic into a global pandemic. As yet, no effective drugs have been found to treat this virus. This study, an ongoing multicenter and blind randomized controlled trial (RCT), is being conducted at ten study sites in Heilongjiang Province, China, to investigate the efficacy and safety of Triazavirin (TZV) versus its placebo in COVID-19 patients. A total of 240 participants with COVID-19 are scheduled to be enrolled in this trial. Participants with positive tests of throat swab virus nucleic acid are randomized (1:1) into two groups: standard therapy plus TZV or standard therapy plus placebo for a 7-day treatment with a 21-day follow-up. The primary outcome is the time to clinical improvement of the subjects. Secondary outcomes include clinical improvement rate, time to alleviation of fever, mean time and proportion of obvious inflammatory absorption in the lung, conversion rate of repeated negative virus nucleic acid tests, mortality rate, and conversion rate to severe and critically severe patients. Adverse events, serious adverse events, liver function, kidney function, and concurrent treatments will be monitored and recorded throughout the trial. The results of this trial should provide evidence-based recommendations to clinicians for the treatment of COVID-19.     

On the Detection of COVID-19 from Chest X-Ray Images Using CNN-Based Transfer Learning

Coronavirus disease (COVID-19) is an extremely infectious disease and possibly causes acute respiratory distress or in severe cases may lead to death. There has already been some research in dealing with coronavirus using machine learning algorithms, but few have presented a truly comprehensive view. In this research, we show how convolutional neural network (CNN) can be useful to detect COVID-19 using chest X-ray images. We leverage the CNN-based pre-trained models as feature extractors to substantiate transfer learning and add our own classifier in detecting COVID-19. In this regard, we evaluate performance of five different pre-trained models with fine-tuning the weights from some of the top layers. We also develop an ensemble model where the predictions from all chosen pre-trained models are combined to generate a single output. The models are evaluated through 5-fold cross validation using two publicly available data repositories containing healthy and infected (both COVID-19 and other pneumonia) chest X-ray images. We also leverage two different visualization techniques to observe how efficiently the models extract important features related to the detection of COVID- 19 patients. The models show high degree of accuracy, precision, and sensitivity. We believe that the models will aid medical professionals with improved and faster patient screening and pave a way to further COVID-19 research.